Gardner Sr, William /1-
fin
NEW YORK STATE DEPARTMENT OF HEALTH ' 414 a 3 t
Burial - Transit rermit
Vital Records Section .0. u
Name First Middle Last (� Sex
l f //i k1 C' - Gris aiv'E i-- Ste--. /iA%
Date of Death Age If Veteran of U.S. Armed Forces,
C/3 „ Ca' _ lc/� k'" War or Dates !"- C
Plac- : ath �} Hospital, Institution or
X City, Town •r Village • (/ ' 7i J Q.1((,'!q Street Address 7' Qceu it; e 1/y / 6_.
0. Mann- z Death EYNatural Cause [-]Accident 0 Homicide Suicide C7 Undetermined Pending
Circumstances Investigation
. Medical Certifier Name Title
Z r►-A,v c is L,r t- ,m
Address
b 6o7' -7G ,a it-- al ci e a / /.2 F y‘
Death Certificate Filed District Number i / ' Register Number a
City, Town or Village Mk i-v A I 'S
igi[]Burial Date Cempery or Crematory
❑Entombment Address
( Cremation �Ir'e Q k s b L r,y /`-'7 i
Date Place Removed
Z❑Removal and/or Held
and/or Address
E` Hold
Cil
Date Point of
4L El Transportation Shipment
3 by Common Destination
Carrier
Ell Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Mi Permit Issued to . 7 / Registration Number
Name of Funeral Home E (,i,�sa I Ke!/v f-,,'fi;ti>-a( ji — C-t?6---( y
Address /
il Name of Funeral Firm Making Disposition or to VVilom
Remains are Shipped, If Other than Above
Address
1Z
til
Permission is hereby granted to dispose of the human e ins described above as indicated.
gii Date Issued e. - - /6/ Registrar of Vital Statistics - (--\��-� --
(signature)
`i District Number /`, 3
'7 Place V liek rtiA /U
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 5/101r(,, Place of Disposition gag-, a,ry►e4r---
2 (address)
Ili
C (section) (lot number)) (grave number)
o
Name of Sexton or Person in Charge of Premises tLrr i L J i. Ar
(ease print)
W.` 4 i441. SignatureTitle aCitlAti
(over)
DOH-1555 (02/2004)